The initiative
Over the last decade, Chile has taken an intersectoral approach to policymaking, with the aim of decreasing socioeconomic inequality and improving health outcomes. One example of this approach is Chile Crece Contigo [Chile Grows with You] (CCC), which was launched in 2007 by the then president, Michelle Bachelet, which is one of the initiatives leading to universal healthcare. It provides “a universal platform to support early child development for all [under-fives] and for all pregnant women”. [2]
CCC was given legislative force with the passing of Law 20.379 in 2009, which created “the Intersectoral Social Protection System and institutionalised CCC, thus becoming a stable public policy”. [3] It has the following objectives:
- To accompany, protect, and fully support all children and their families through universal actions and services.
- To target special support to vulnerable children and families (“to each according to their needs”).
- To monitor the developmental trajectory of children, from pregnancy the pregnancy of the mother until the child’s entry into the school system.
- To take a multidimensional approach, offering support in health, education, social, and community spheres.
- Providing “an integrated system of benefits, interventions and social services to support the child and his/her family … to develop their maximum potential, in order to [create equality in] development opportunities”. [4]
CCC was initially rolled out in 159 comunas (small regions) in 2007, then expanded to all in 2008. Mothers enter CCC at their first prenatal checkup, and engage with the system throughout their pregnancy and birth. Before birth, children are enrolled and have access to healthcare and pre-primary education. Any vulnerabilities detected (e.g., postnatal depression, developmental delay in the child, domestic abuse) will trigger the intervention of the appropriate health and social services professionals.
The challenge
In 2011, Chile had one of the most severe poverty gaps in the world. “With a Gini coefficient of 0.51, Chile has the highest level of income inequality after government taxes and transfers among OECD countries.” [1]
Despite the establishment of universal healthcare coverage in 2005, Chile’s child and infant mortality and morbidity statistics vary widely from region to region, and this is largely a consequence of its socioeconomic disparities.
The public impact
The CCC programme has had a significant impact on the health and welfare of low-income Chileans:
- The poorest 60 percent of households have free access to nurseries and preschools, as do vulnerable families and those with special need.
- Families across Chile now have guaranteed access to antenatal care, professional care during birth, comprehensive care for children in hospitals, improved children’s health checks, and improved interventions for vulnerable children and those with developmental problems.
Stakeholder engagement
The Chilean government is the primary stakeholder. All the relevant government agencies (in education, health and social development) are highly engaged and collaborating to ensure the success of CCC.
The regional governments and comunas are also strongly engaged, as are education, healthcare and social service providers.
Political commitment
The CCC policy was developed by Michelle Bachelet’s Socialist Party government in 2007, before being enshrined in legislation – the unanimously approved Law 20.379 – by Sebastián Piñera Echenique’s National Renewal government. CCC has continued to grow, despite another change of government in 2013 (a return to Socialist Party rule under Michelle Bachelet).
The government funded CCC, despite its relatively high costs (more than US$10 billion for the first two years alone), which further indicates that there is strong cross-party political commitment. Local government has also shown commitment to the scheme by facilitating its rollout.
Public confidence
There are a number of indicators of Chilean citizens’ confidence in CCC:
- Thousands of Chileans attended public consultation events or submitted feedback online during its development.
- Between 2007 and 2014, nearly one million pregnant women enrolled in CCC.
- The CCC website had 121,000 visits per month in 2013.
- There were “high levels of user satisfaction for [the] biopsychosocial programme and newborn programme: 81% and 94%, respectively”. [5]
Clarity of objectives
CCC’s objectives were clearly defined and have so far been maintained: providing healthcare to all under-fives and their families, as well as support in the spheres of education, social, and community services.
However, there is no evidence of quantifiable objectives, either for the use of its services or for its role in closing Chile’s poverty gap.
Strength of evidence
CCC is a strong example of evidence-based policymaking:
- The Presidential Advisory Council assessed scientific literature and case studies from around the world, expert opinions, and feedback from Chilean adults and children to develop the CCC policy.
- CCC was initially rolled out in a subset of regions before being provided to the whole of Chile.
- The Chilean government collects statistics on CCC outcomes and uses these to inform future decision-making.
- “Scientific evidence – consolidation and universal application of successful experiences and services (national and international evidence), ‘window of opportunity’ (high impact of the work done during early childhood), return on investment.” [6]
Feasibility
Before the initial rollout, the CCC team considered financial, HR, technical, and legal feasibility:
- Financial – CCC was supported by significant government funding. “According to budget performance reporting, spending
- conducted by the Ministry of Social Development in Chile Grows with You [CCC] reached US$2.7 billion for 2007 (the initial installation phase), US$8.1 billion in 2008 (the expansion phase) and US$27.6 billion for 2009.” [7]
- HR – meetings were held to allow local health practitioners, social workers, childcare providers, and so on to meet each other and learn about their roles in the roll-out of CCC. Training programmes were also designed and delivered to ensure local actors were capable of supporting CCC.
- Technical – software was designed to allow all providers across the network to enter data about enrolled families and track their children’s progress.
- Legal – CCC was enshrined in Law 20.379 and became part of the Chilean legislative framework.
Management
CCC is a national initiative, and is managed at national, regional, and local levels:
- Executive management – a committee of ministers of social development (in the Ministries of Social Development, of Health, of Planning and of Education) is responsible for the development, planning, and budgeting.
- The Ministry of Health is responsible for executing the biopyschosocial development programme, as well as antenatal care and child health.
- The Ministry of Education is charged with ensuring the quality of preschool education.
- Regional and provincial management [is provided] through the regional secretariats for Health, Social Development, and Education.” [8]
- Municipalities are served by child and family services – “Local Intervention Network, Infancy Unit [and the] Primary Care Centre Entry Point”. [9]
Measurement
Alignment
There is good alignment between:
The government departments principally engaged in rolling out CCC, i.e., the Ministries of Social Development, of Health, and of Education.
Between national and regional administrations and the local providers of healthcare, education, and social support.
Resources
2011, World Health Organization
2014, The Lancet
ABOUT CHILE GROWS WITH YOU: Presentation System, Chile crece contigo
31 AUGUST 2007, Country Case Studies on Intersectoral Action for Health, WHO Commission on Social Determinants of Health